Medical Terminology and Documentation
What this domain tests
This domain tests word building, common prefixes, roots and suffixes, safe abbreviation practice, and documentation standards such as SOAP and ISBAR. Questions check whether you can decode unfamiliar terms and write a record that is accurate, timely and legally defensible.
Core rules
- Medical terms combine a prefix, a root and a suffix. The suffix often gives the condition, procedure or process; the prefix gives location, number, time or degree.
- Common roots include cardi- (heart), pulmon- (lung), hepat- (liver), nephr- (kidney), gastr- (stomach), neur- (nerve) and derm- (skin).
- Common suffixes include -itis (inflammation), -ectomy (removal), -otomy (incision), -ostomy (opening), -aemia (blood condition), -uria (urine condition) and -plasia (formation).
- Add a combining vowel, usually o, when the suffix begins with a consonant.
- Avoid error-prone abbreviations: write units in full, avoid U for units, avoid QD and QOD, and do not use abbreviations on the dangerous-abbreviation list.
- Documentation should be accurate, objective, complete, contemporaneous, confidential and attributable. SOAP separates subjective, objective, assessment and plan. ISBAR structures handover by introduction, situation, background, assessment and recommendation.
- If you make a late entry, label it as a late entry with the date, time and reason.
Worked example
Break down pericarditis: peri- means around, cardi- means heart, and -itis means inflammation. The term therefore means inflammation around the heart, specifically the pericardium. The reasoning is to identify each component, confirm the root's meaning, then combine them into a precise anatomical description rather than guessing from the whole word.
Traps that cost marks
- Writing patient is stable without vital signs or objective findings.
- Using abbreviations that can be misread, such as U for units or QD for daily.
- Copying forward another clinician's note without verifying it.
- Backdating an entry instead of labelling it as late.
- Recording interpretations such as anxious when you observed pacing and rapid speech.